"I'm Dr. Jack Stapleton," Jack blurted. "I'm a medical examiner here in the city. Listen! You've had a series of unexpected cardiac deaths in this hospital since January. All have been unsuccessful resuscitation attempts on young healthy people just like this patient. A red flag has gone up over at the OCME. We think it's purposeful, iatrogenic hyperkalemia."
"We've got almost nothing on EKG," one of the residents announced, standing by the machine mounted on the crash cart. EKG tape was spewing out the side, tracing poorly formed complexes.
Caitlin grabbed a quick look. Whatever she saw pushed her over the edge into Jack's camp, and she began barking out orders that had the nurses scurrying. She wanted calcium gluconate; she wanted twenty units of regular insulin along with a fifty-gram dose of glucose; she wanted sodium bicarbonate; she wanted cation-exchange resin set up for a retention enema; she wanted blood sent for stat electrolytes; and, most important from Jack's perspective, she wanted a surgical resident paged to help with emergency peritoneal dialysis. In Jack's mind, it was the dialysis that could potentially save the day.
While the nurses were busy carrying out the orders and obtaining and drawing up all the medication, one of the male residents climbed up on the bed and relieved a reluctant Jack, but as soon as the man started his compressions, Jack acknowledged the resident was probably doing a better job. As an ophthalmologist-turned-medical examiner, Jack was out of practice when it came to CPR. He was also exhausted, but it was hard for him to stand there at the foot of the bed and do nothing while Laurie's life hung in the balance. While concentrating on doing the chest compressions, he'd been less able to think about the potential tragedy of what he was witnessing.
Jack hadn't run all the way from the OCME to the Manhattan General Hospital, but he had run quite far just the same. He'd run almost ten blocks up First Avenue without seeing an empty taxi. A number of cars had passed him and sprayed him with water, but none had stopped. Then his luck changed. Near the UN headquarters, a police patrol car had pulled over in front of him, apparently thinking he was fleeing from a crime. When Jack flashed his medical examiner badge and breathlessly said he was on an emergency run to the Manhattan General, the police had told him to jump in. They took him nonstop with their siren blaring. If it had crossed their minds why a medical examiner who deals with dead bodies had an emergency in the middle of the night requiring him to sprint up First Avenue, they hadn't let on.
As Laurie's hyperkalemic treatment began to bring down the high potassium that Jack feared was coursing around in her blood, an anesthesiologist showed up. He proceeded to deftly intubate Laurie so she could be respired with more certainty. When he straightened up after finishing the procedure, Jack caught his name. It was José Cabreo, and Jack did a double take. He remembered the man's name from Roger's lists. Jack found himself watching José's every move and was relieved when the anesthesiologist quickly left.
The peritoneal dialysis was started percutaneously without a hitch, using a large bore trocar. Jack averted his eyes as the trocar was punched through Laurie's abdominal wall, but he was close enough to hear the popping sound it made as it went through the fascia, and he winced. A moment later, he watched as isotonic fluid free of potassium was then run into her abdomen. Jack secretly crossed his fingers and prayed that the procedure would help. He was aware that with the extensive surface area within the abdomen as a result of the loops of intestine combined with the rich plexus of blood vessels, peritoneal dialysis was the most efficient even if passive way to lower potassium or any other elevated electrolyte in the blood.
Unfortunately, after ten minutes of the aggressive therapy, there was disappointingly little change in Laurie's status. Caitlin ordered more calcium gluconate and injected it herself. Jack heard this from afar, as he'd begun pacing between Laurie's bed in front of the nurses' station and the elevator lobby. It wasn't the caffeine that was propelling him now, it was his mounting fear and guilt. His nagging concern was that this episode might be another instance of his being a jinx to those he loved. The thought haunted him mercilessly. In one night, he already had lost a potential child; now he was on the verge of losing the person he loved. To make matters worse, he knew he was at least partially to blame.
When the stat Woodwork came back, Caitlin brought it over to Jack. "Well, you were absolutely right," she said while pointing to the highlighted abnormally high potassium level. "That's about as high as I've ever seen it. After this is all over, I'd like to hear how you knew."
"I'll be happy to tell you," Jack said, "provided Miss Montgomery pulls through." If Laurie didn't make it, he didn't know if he'd be willing to talk to anybody.
"We're doing our best," Caitlin said. "At least her color is good and her pupils have definitely come down."
As the minutes inexorably passed, Jack kept his distance. As a bystander, it was progressively upsetting to him to see Laurie splayed out on the bed with a stranger pounding on her chest and another dispassionately squeezing the breathing bag. The ambulatory patients who had earlier come to their respective doors to watch the unfolding drama had gone back to their beds. Most of the floor nurses had also been called away by the needs of their own patients.
It was twenty minutes to six when the first truly optimistic sign occurred, and it was Caitlin who noticed it. "Hey! Gang!" she shouted. "We're getting some electrical activity in the heart!" The medical resident who was not currently doing either the closed chest massage or the breathing-bag compression rushed over to the EKG machine to look over Caitlin's shoulder. "Send off another stat potassium level," Caitlin yelled to the nurse who was assisting them.
"Wow! Those complexes are starting to look quite normal," the resident said to Caitlin, who nodded in agreement. "And they are getting better."
"Hold up on the compressions!" Caitlin called out to the resident, who was kneeling on the bed over Laurie. "See if she's got a pulse!"
The resident who had been breathing for Laurie also stopped long enough to feel along Laurie's neck for a pulse. "She's got a pulse! And, my gosh, she's breathing on her own!" He took the mask away from the end of the endotracheal tube. With his palm, he could feel the amount of air she was breathing in and out. "She's breathing pretty darn normally, and she's bucking the endotracheal tube."
"Deflate it and pull it out!" Caitlin ordered. "Her EKG now looks completely normal."
The resident quickly followed orders and slipped the tube out of Laurie's mouth but still held her chin back to make sure her airway stayed open. Laurie coughed several times.
Hearing these exchanges, Jack rushed back from where he was pacing in the darkened elevator lobby and went behind the nurses' station desk. Laurie had been connected to one of the monitors built in over the desk, but to see it, one had to be on the opposite side of the counter from where the action was. A half hour earlier when he'd looked at it, the blips for the blood pressure and pulse had been tracing straight lines across the screen. It was different now, and his heart leaped in his chest. Laurie had both a pulse and blood pressure!
"Hold up on the peritoneal dialysis!" Caitlin ordered. "And drain out the cation exchange resin. We don't want to overshoot and then have to worry about too low a potassium level."
Jack rounded the nurses' station counter. There was once again a flurry around Laurie as Caitlin's latest orders were carried out. Jack didn't want to get in the way, but as hopeful as these developments were, he wanted to be close to her.
"Hallelujah!" said the resident who had been most recently breathing for Laurie. "She's waking up!"